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Application Forms

all fields must be completed


Saxon Mortgage Service is licensed under the data protection act 1998 licence No. Z9726855
and Also holds a credit consumer licence No. 595189 from the office of fair trading

This information will be sent to an adviser at Saxon Mortgage Services not direct to the Insurance company,
who will call you to clarify any issues on this form.

This form enables us to give you a more accurate quotation and saves you time on the telephone.

You voluntarily choose to provide personal details to us via this website.
Personal information will be treated as confidential by us and held in accordance with the Data Protection Act 1998.
You agree that such personal information may be used to provide you with details of services and products in writing, by email or by telephone.



    Single Applicant

    Dual Applicants
  
  
Single Applicant     
(1)  Surname:     
(2)  Forenames:     
(3)  Title Select      
  
(4)  Number / House Name:     
(5)  Road:     
(6)  District:     
(7)  Town:     
(8)  County:     
(9)  Post Code:     
(10)  Are you about to change your address: Yes No    
  
  
Phone Numbers:     
(11)  Day:     
(12)  Evening:     
(13)  Mobile:     
(14)  Best time to call ? Select 
  
  
(15)  Date of Birth Day  Mth  Yr 
(16)  Marital status select     
  
  
(17)  Amount of Cover:     
(18)  Term:     
  
  
(19)  Is Critical Illness Required: Yes No    
  
  
(20)  Occupation:     
(21)  Which Industry do you work in: Select      
(22)  Does your occupation require you to work regularly above 40 feet: Yes No    
(23)  Are you a member of the armed forces: Yes No    
  
  
(24)  Please state your height Ft  In  Mtr 
  
(25)  Please state your Weight[?]
 St  Pds  Kls 
  
  
(26)  Have you smoked
in the last 12 months:		 Yes No    
  
(27)  Have you used other tobacco products or nicotine replacement products in the last 12 months: Yes No    
  
(28)  Do you consume alcohol [?]
 Select 
  
(29)  Have you taken recreational drugs such as cocaine or heroin in the last 5 years: Yes No    
  
(30)  Have you any prospect of living or working abroad or have done so in the last 5 years: [?]
 Yes No    
  
(31)  Do you or intend to take part in any hazardous activity e.g. [?]
 Select 
  
(32)  Have you ever had or been advised to have blood test, investigations or operations: [?]
 Yes No    
  
(33)  Have you consulted a doctor in the last 5 years or are you intending to seek advice: Yes No    
  
(34)  Are you on any treatment such as medicine or tablets: Yes No    
  
(35)  Has any member of your family suffered from any hereditary illness or died before they where 60 Select 
  
(36)  Do you suffer from Type One diabetes. Select 
  
(37)  Do you suffer from Type TWO diabetes. Select 
  
(38)  Do you suffer from Asthma. Select 
  
(39)  Have you had any application for Life Insurance subjected to any of the following. Select 
  
(40)  Have you been exposed to the risk of infection from HIV in the last 5 years: Yes No    
  
(41)  Have you ever tested positive for HIV / AIDS or Hepatitis B or C: Yes No    
  
(42)  Have you tested Positive or been treated for more than 1 episode of a S. T. D: Yes No    
  
(43)  Have you ever had surgery or received Blood products from outside the E.U.: Yes No    

If you have answered YES to any of these questions give details in notes

Notes
Number of Policy Holders: 1 2 3 4
  
  
Applicant A      Applicant B
(A 1)  Surname:      (B 1)  Surname:
(A 2)  Forenames:      (B 2)  Forenames:
(A 3)  Title      (B 3)  Title:     
  
(A 4)  Number / House Name:      (B 4)  Number / House Name:
(A 5)  Road:      (B 5)  Road:
(A 6)  District:      (B 6)  District:
(A 7)  Town:      (B 7)  Town:
(A 8)  County:      (B 8)  County:
(A 9)  Post Code:      (B 9)  Post Code:
(A 10)  Are you about to change your address: Yes No     (B 10)  Are you about to change your address: Yes No
  
  
Phone Numbers:      Phone Numbers:
(A 11)  Day:      (B 11)  Day:
(A 12)  Evening:      (B 12)  Evening:
(A 13)  Mobile:      (B 13)  Mobile:
(A 14)  Best time to call ? (B 14)  Best time to call ?
  
  
(A 15)  Date of Birth (B 15)  Date of Birth
(A 16)  Marital status      (B 16)  Marital status     
  
  
(A 17)  Amount of Cover:      (B 17)  Amount of Cover:
(A 18)  Term:      (B 18)  Term:
  
  
(A 19)  Is Critical Illness Required: Yes No     (B 19)  Is Critical Illness Required: Yes No
  
  
(A 20)  Occupation:      (B 20)  Occupation:
(A 21)  Which Industry do you work in:      (B 21)  Which Industry do you work in:     
(A 22)  Does your occupation require you to work regularly above 40 feet: Yes No     (B 22)  Does your occupation require you to work regularly above 40 feet: Yes No
(A 23)  Are you a member of the armed forces: Yes No     (B 23)  Are you a member of the armed forces: Yes No
  
  
(A 24)  Please state your height (B 24)  Please state your height
  
(A 25)  Please state your Weight[?]
 (B 25)  Please state your Weight[?]
  
  
(A 26)  Have you smoked
in the last 12 months:		 Yes No     (B 26)  Have you smoked
in the last 12 months:		 Yes No
  
(A 27)  Have you used other tobacco products or nicotine replacement products in the last 12 months: Yes No     (B 27)  Have you used other tobacco products or nicotine replacement products in the last 12 months: Yes No
  
(A 28)  Do you consume alcohol [?]
 (B 28)  Do you consume alcohol [?]
  
(A 29)  Have you taken recreational drugs such as cocaine or heroin in the last 5 years: Yes No     (B 29)  Have you taken recreational drugs such as cocaine or heroin in the last 5 years: Yes No
  
(A 30)  Have you any prospect of living or working abroad or have done so in the last 5 years: [?]
 Yes No     (B 30)  Have you any prospect of living or working abroad or have done so in the last 5 years: [?]
 Yes No
  
(A 31)  Do you or intend to take part in any hazardous activity e.g. [?]
 (B 31)  Do you or intend to take part in any hazardous activity e.g. [?]
  
(A 32)  Have you ever had or been advised to have blood test, investigations or operations: [?]
 Yes No     (B 32)  Have you ever had or been advised to have blood test, investigations or operations:[?]
 Yes No
  
(A 33)  Have you consulted a doctor in the last 5 years or are you intending to seek advice: Yes No     (B 33)  Have you consulted a doctor in the last 5 years or are you intending to seek advice: Yes No
  
(A 34)  Are you on any treatment such as medicine or tablets: Yes No     (B 34)  Are you on any treatment such as medicine or tablets: Yes No
  
(A 35)  Has any member of your family suffered from any hereditary illness or died before they where 60 (B 35)  Has any member of your family suffered from any hereditary illness or died before they where 60
  
(A 36)  Do you suffer from Type ONE diabetes (B 36)  Do you suffer from Type ONE diabetes
  
(A 37)  Do you suffer from Type TWO diabetes. (B 37)  Do you suffer from Type TWO diabetes
  
(A 38)  Do you suffer from Asthma. (B 38)  Do you suffer from Asthma.
  
(A 39)  Have you had any application for Life Insurance subjected to any of the following. (B 39)  Have you had any application for Life Insurance subjected to any of the following.
  
(A 40)  Have you been exposed to the risk of infection from HIV in the last 5 years: Yes No     (B 40)  Have you been exposed to the risk of infection from HIV in the last 5 years: Yes No
  
(A 41)  Have you ever tested positive for HIV / AIDS or Hepatitis B or C: Yes No     (B 41)  Have you ever tested positive for HIV / AIDS or Hepatitis B or C: Yes No
  
(A 42)  Have you tested Positive or been treated for more than 1 episode of a S. T. D: Yes No     (B 42)  Have you tested Positive or been treated for more than 1 episode of a S. T. D: Yes No
  
(A 43)  Have you ever had surgery or received Blood products from outside the E.U.: Yes No     (B 43)  Have you ever had surgery or received Blood products from outside the E.U.: Yes No

If you have answered YES to any of these questions give details in notes

NotesNotes